Stefania Pigatto Teche

The multidimensional evaluation and treatment of anxiety in children and adolescents: rationale, design, methods and preliminary findings

OBJECTIVE This study aims to describe the design, methods and sample characteristics of the Multidimensional Evaluation and Treatment of Anxiety in Children and Adolescents - the PROTAIA Project. METHOD Students between 10 and 17 years old from all six schools belonging to the catchment area of the Primary Care Unit of Hospital de Clínicas de Porto Alegre were included in the project. It comprises five phases: (1) a community screening phase; (2) a psychiatric diagnostic phase; (3) a multidimensional assessment phase evaluating environmental, neuropsychological, nutritional, and biological factors; (4) a treatment phase, and (5) a translational phase. RESULTS A total of 2,457 subjects from the community were screened for anxiety disorders. From those who attended the diagnostic interview, we identified 138 individuals with at least one anxiety disorder (apart from specific phobia) and 102 individuals without any anxiety disorder. Among the anxiety cases, generalized anxiety disorder (n = 95; 68.8%), social anxiety disorder (n = 57; 41.3%) and separation anxiety disorder (n = 49; 35.5%) were the most frequent disorders. CONCLUSION The PROTAIA Project is a promising research project that can contribute to the knowledge of the relationship between anxiety disorders and anxiety-related phenotypes with several genetic and environmental risk factors.

Evidence of association between Val66Met polymorphism at BDNF gene and anxiety disorders in a community sample of children and adolescents

Different lines of evidence support BDNF as a candidate gene in mood and anxiety modulation. More recently, the Met allele of the BDNF Val66Met polymorphism has been implicated in anxiety in animal models and anxiety-traits in humans. The aim of this study is to evaluate the a priori hypothesis that the association between anxiety disorders and Val66Met polymorphism at the BDNF gene would be replicated in a community sample of children and adolescents. 240 subjects from a total sample of 2457 children and adolescents aged 10-17 years from the public schools in the catchment area of the primary care unit of a university hospital participated in this case-control study and were assessed for psychopathology using the K-SADS-PL. A sample of saliva was collected for DNA analysis of Val66Met polymorphism. BDNF was the single gene evaluated in this sample. We found a significant association between carrying one copy of the Met allele and higher chance of anxiety disorders in children and adolescents. The association remained positive even after the adjustment for potential confounders (228 subjects; OR=3.53 (CI95% 1.77-7.06; p<0.001)). Our results support the a priori hypothesis of an association between anxiety and the polymorphism Val66Met. To our knowledge, this is the first study documenting a potential role of this polymorphism in a community sample of anxious children and adolescents.

Resilience to traumatic events related to urban violence and increased IL10 serum levels

The exposition to traumatic events related to urban violence is epidemic in Brazil, with rate of 80% in the general population, and is becoming a major cause of post-traumatic stress disorder (PTSD). The objective of the study was to compare serum levels of pro-inflammatory interleukin-6 (IL-6) and anti-inflammatory interleukin-10 (IL-10) in PTSD and resilient individuals. We hypothesized that resilient individuals present an attenuated pro-inflammatory and enhanced anti-inflammatory state. We conducted a case-control study comparing 30 resilient individuals and 30 PTSD patients exposed to traumatic events related to urban violence. The groups were evaluated using Self-Report Questionnaire (SRQ-20), Mini-International Neuropsychiatric Interview (MINI) and the Davidson Trauma Scale. For all individuals, blood samples were collected to determine IL-6, IL-10 and cortisol serum levels. All samples were frozen at -80°C until the assay and were analyzed with the same immunoassay kit and in duplicates. The resilient group presented higher IL-10 levels than PTSD patients [mean (CI95%); 1.03 (0.52-2.08) pg/mL vs. 0.29 (0.20-0.43) pg/mL; P=0.002]. There were no differences in terms of IL-6 or cortisol levels. The results provided evidence for increased levels of IL-10 in resilient individuals when compared to PTSD patients, probably conferring them a better anti-inflammatory response after exposition.

Therapeutic relationship on the web: to face or not to face?

In this age of unprecedented expansion of media and information dissemination and sharing, the use of electronic means should be reconsidered. The use of new technologies should be studied to understand how it may affect the relationship between patient and therapist during psychotherapy or psychoanalytic treatments. This study offers a critical discussion of the effect of technologies on clinical practice, and vignettes are used to describe their impact on frame, anonymity, abstinence and therapeutic neutrality. Transfer and countertransference issues resulting from these changes are also discussed. The potential benefits of new technologies in psychotherapy are appreciated, but the authors draw attention to the need to reflect about the presence of the therapist in those technologies and the preservation of the therapeutic setting, so that a satisfactory progression of the work of the dyad is ensured. This study also discusses the use of technologies in the expansion of learning and application of the therapeutic technique to overcome geographic and time barriers, among others.

Internalizing disorders and quality of life in adolescence: evidence for independent associations

OBJECTIVE To investigate whether internalizing disorders are associated with quality of life (QoL) in adolescents, even after accounting for shared risk factors. METHODS The sample comprised 102 adolescents from a community cross-sectional study with an oversampling of anxious subjects. Risk factors previously associated with QoL were assessed and divided into five blocks organized hierarchically from proximal to distal sets of risk factors. RESULTS Multiple regression analysis yielded a hierarchical model accounting for 72% of QoL variance. All blocks were consistently associated with QoL (p < 0.05), accounting for the following percentages of variance: 12% for demographics; 5.2% for family environment; 37.8% for stressful events; 10% for nutritional and health habits; and 64.2% for dimensional psychopathological symptoms or 22.8% for psychiatric diagnoses (dichotomous). Although most of the QoL variance attributed to internalizing symptoms was explained by the four proximal blocks in the hierarchical model (43.2%), about 21% of the variance was independently associated with internalizing symptoms/diagnoses. CONCLUSIONS QoL is associated with several aspects of adolescent life that were largely predicted by our hierarchical model. Our findings reinforce the hypothesis that internalizing disorders and internalizing symptoms in adolescents have a high impact on QoL and deserve proper clinical attention.

Countertransference and therapeutic alliance in the early stage of adult psychodynamic psychotherapy

OBJECTIVES The primary objective of this study was to assess the relationship between countertransference (CT) and therapeutic alliance (TA) during the early stages of psychodynamic psychotherapy. A secondary objective is to assess associations between CT and variables related to therapist and patient and between CT and other patient variables investigated, which were defense mechanisms, symptomology and functionality. METHODOLOGY This was a cross-sectional study that enrolled 30 patients treated by 17 different therapists at the psychotherapy clinics of two psychiatry centers. Assessments of each patient-therapist pair were conducted between their fourth and 10th sessions. RESULTS The CT distance domain exhibited a moderate negative correlation with TA, particularly its sub-dimension representing the patients capacity for work in therapy. Moderate positive correlations were observed between CT distance and the splitting defense mechanism and between CT closeness and suppression defenses, in addition to moderate negative correlation between CT indifference and the fantasy defense mechanism. Another finding was higher scores for CT indifference in association with socioeconomic classes D and E. CONCLUSIONS The quality of CT may provide a source of information about TA. A high degree of CT distance represents a low level of TA, particularly with relation to the patients working capacity, although presence of the splitting defense mechanism can affect CT, to the extent that it constitutes a confounding variable. The concept of CT is useful to psychotherapists, providing a source of information about the patients internal world and about certain elements of therapy, such as the quality of TA, which is important for good treatment results.

Association between resilience and posttraumatic stress disorder among Brazilian victims of urban violence: a cross-sectional case-control study

Introduction This study investigated the association between resilience and posttraumatic stress disorder (PTSD) among Brazilian victims of urban violence. It also compared defense mechanisms, parental bonding, and childhood trauma between those who developed PTSD and those who did not. Methods This cross-sectional case-control study included 66 adult subjects exposed to recent urban violence in southern Brazil - 33 with PTSD and 33 healthy controls matched by sex and age - who were administered the Resilience Scale, Defense Style Questionnaire, Parental Bonding Instrument, and Childhood Trauma Questionnaire. The statistical tests used were the McNemar test for categorical variables, the Wilcoxon signed-rank test for continuous asymmetric variables, and the paired Student t-test for continuous symmetric variables. Results The PTSD group showed lower total Resilience Scale scores compared with controls (128.4±20.7 vs. 145.8±13.1, respectively; p = 0.01), along with a lower ability to solve situations and lower personal values that give meaning to life (p = 0.019). They also had lower rates of mature defense mechanisms (p < 0.001) and higher rates of emotional (p = 0.001) and physical (p = 0.003) abuse during childhood. Conclusion Lower levels of resilience, especially the ability to solve situations and having personal values that give meaning to life, immature defense mechanisms, and emotional and physical abuse in childhood are associated with PTSD in adult Brazilian victims of urban violence.

Further replication of the synergistic interaction between LPHN3 and the NTAD gene cluster on ADHD and its clinical course throughout adulthood

Attention-Deficit/Hyperactivity Disorder (ADHD) is a common and highly heritable neuropsychiatric disorder. Despite the high heritability, the unraveling of specific genetic factors related to ADHD is hampered by its considerable genetic complexity. Recent evidence suggests that gene-gene interactions can explain part of this complexity. We examined the impact of strongly supported interaction effects between the LPHN3 gene and the NTAD gene cluster (NCAM1-TTC12-ANKK1-DRD2) in a 7-year follow-up of a clinical sample of adults with ADHD, addressing associations with susceptibility, symptomatology and stability of diagnosis. The sample comprises 548 adults with ADHD and 643 controls. Entropy-based analysis indicated a potential interaction between the LPHN3-rs6551665 and TTC12-rs2303380 SNPs influencing ADHD symptom counts. Further analyses revealed significant interaction effects on ADHD total symptoms (p=0.002), and with hyperactivity/impulsivity symptom counts (p=0.005). In the group composed by predominantly hyperactive/impulsive and combined presentation, the presence of LPHN3-rs6551665 G allele was related to increased ADHD risk only in individuals carrying the TTC12-rs2303380 AA genotype (p=0.026). Also, the same allelic constellation is involved in maintenance of ADHD in a predominantly hyperactive/impulsive or combined presentation after a 7-year follow-up (p=0.008). These observations reinforce and replicate previous evidence suggesting that an interaction effect between the LPHN3 gene and the NTAD cluster may have a role in the genetic substrate associated to ADHD also in adults. Moreover, it is possible that the interactions between LPHN3 and NTAD are specific factors contributing to the development of an ADHD phenotype with increased hyperactivity/impulsivity that is maintained throughout adulthood.